International Emergency Nursing 23 (2015) 150–155

Contents lists available at ScienceDirect

International Emergency Nursing j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / a a e n

Professional environment and patient safety in emergency departments Persefoni Lambrou PhD(c) (Doctoral Student) *, Evridiki Papastavrou PhD (Assistant Professor), Anastasios Merkouris PhD (Associate Professor – Deputy Chair Acting Dean, School of Health Sciences), Nicos Middleton PhD (Assistant Professor) Cyprus University of Technology, Department of Nursing, School of Health Sciences, 15, Bragadinou str., 3041, Limassol, Cyprus

A R T I C L E

I N F O

Article history: Received 7 May 2014 Received in revised form 19 July 2014 Accepted 28 July 2014 Keywords: Emergency department Professional environment Patient safety Physician Nurse

A B S T R A C T

The purpose of this study was to examine nurses’ and physicians’ perceptions of professional environment and its association with patient safety in public emergency departments in Cyprus. A total of 224 professionals (174 nurses and 50 physicians) participated (rr = 81%). Data were collected using the “Revised Professional Practice Environment” (RPPE) instrument and the Safety Climate Domain of the “Emergency Medical Services Safety Attitudes Questionnaire” (EMS-SAQ). The mean overall score of RPPE was 2.79 (SD = 0.30), among physicians 2.84 (SD = 0.25) and nurses 2.73 (SD = 0.33) (P-value = 0.07). Statistically significant differences were observed between the two study groups regarding “staff relationships”, “motivation” and “cultural sensitivity” (P-values < 0.05). No significant differences were observed as regards EMS-SAQ (3.25 vs. 3.16 respectively; P-value = 0.28). All 8 components of the RPPE exhibited significant association with patient safety. Linear and stepwise regression analyses showed that “leadership” explains 28% of the variance of safety. This relationship suggests improvements in professional environment with the ultimate goal of improving patient safety. © 2014 Elsevier Ltd. All rights reserved.

1. Introduction The World Health Organization (WHO) (Wiskow et al., 2010) indicates that the work environment constitutes an important factor in the recruitment and retention of health professionals, and that the characteristics of the work environment affect the quality of care both directly and indirectly. The complex social environment where health professionals carry out their practice, and where there is a continuous need for health-care workers to make decisions individually, as a group and together with patients, has been named the professional practice environment (Wiskow et al., 2010). Several international health professionals’ associations (International Council of Nurses et al., 2008) suggest that due to the global health workforce crisis, establishing positive practice environments across health sectors is of paramount importance if patient safety and health workers’ wellbeing are to be guaranteed (Wiskow et al., 2010). Improving the practice environment has been shown to be a successful strategy for retention and job satisfaction (Dekeyser Ganz and Toren, 2014). The role of the professional practice

Funding: This study was funded by the Cyprus University of Technology. * Corresponding author. Tel. +357 99685190; fax: +357 25002864. E-mail address: [email protected] (P. Lambrou). http://dx.doi.org/10.1016/j.ienj.2014.07.009 1755-599X/© 2014 Elsevier Ltd. All rights reserved.

environment is crucial for the delivery of quality care as it is correlated with patient and nurse outcomes (Papastavrou et al., 2014b). 2. Background The accident and emergency department, alias emergency department (ED), is a unique location at which patients are guaranteed access to emergency care 24 hours a day, 7 days a week (Ajeigbe et al., 2013). All EDs have an obligation to deliver care that is demonstrably safe and of the highest possible quality. “Safe” refers to “patient safety”, and means freedom from unnecessary harm or potential harm associated with the patient’s health care (Zohar, 1980). Safety culture refers to the shared perceptions or attitudes of a work group toward safety (Zohar, 1980). Recent research has examined safety culture in hospital inpatient settings, intensive care units (ICUs), nursing wards and ambulatory care (Modak et al., 2007; Sexton et al., 2006; Shaw et al., 2009). Few studies, however, have evaluated workplace safety culture in EDs (Patterson et al., 2010). Very few studies that include both physicians and nurses focus on the study of the factors influencing the ED practice environment (Ajeigbe et al., 2013). The importance of a model for the environment was recognized in 1983 with the initial study for Magnet Hospitals, which highlighted three important features namely autonomy, control over practice and professional relationships between nurses and

P. Lambrou et al./International Emergency Nursing 23 (2015) 150–155

physicians. The MGH Professional Practice Model is based on these principles, and it is designed to improve the previous model adopted in 1996 (Erickson et al., 2012). Components of this model are: the vision and values of the organization, the level of quality of care, the organizational culture, professional development, patientcentered care, clinical recognition and development, collaborative decision making, research, teamwork innovation and entrepreneurship. Some of these components have an indirect or direct impact on patient safety. This model guided the development of the original version of the Professional Practice Environment (PPE) Scale (Erickson et al., 2004). In a recent international study with a total sample of 1166 nurses (from Finland, Cyprus, Greece, Portugal, Sweden, Turkey and Kansas, USA) using the Revised Professional Practice Environment Scale, Cypriot nurses gave the lowest scores while United States’ nurses scored the highest assessments of their nursing PPE. Differences between participants from the Nordic EU countries, USA and Mediterranean EU countries as regards RPPE scale were observed (Papastavrou et al., 2012). In another study, conducted in 2011 in nine countries (Aiken et al., 2011), it was found that nurses in hospitals with better professional environments had lower burnout and reported higher satisfaction from their work. Specifically, one third of nurses in South Korea and 60% in Japan reported high levels of burnout reporting that in between 25% and 33% of cases the professional environment was not good. According to a survey carried out in Belgium among 254 nurses in 15 EDs between 2007 and 2008, nurses reported lower professional autonomy and time pressure compared with nurses in other hospital departments (Adriaenssens et al., 2011). A survey conducted among European intensive care nurses in a sample of 255 (Papathanassoglou et al., 2012) showed that “autonomy” is positively correlated with the cooperation of physicians and nurses. Patient safety is a key foundation of good quality health care. The provision of quality care and patient safety is affected by professional practice environment (Laschinger and Leiter, 2006). The importance of patient safety in the emergency departments has been well documented (Ajeigbe et al., 2014; Verbeek-Van Noord et al., 2014; Woloshynowych et al., 2006), but there is a lack of studies examining the association between the professional practice environment and patient safety in these critical hospital areas. This study aims to examine ED’s nurses’ and physicians’ perceptions of their professional practice environment, as well as the extent of the association with their assessment of patient safety across public general hospitals in Cyprus. Given the body of evidence described above, the study hypothesis is that a positive association will be observed between characteristics of the professional environment and perceptions of safety among healthcare professionals. The following research questions were set:

151

3.2. Data collection Data collection took place during June, July and August 2013. 3.3. Sample To be eligible for the study, respondents were required to: (1) Be registered as nurse or physician according to the National Legislation in line with the EU Professional Qualifications Directive (2005/36/EU) (The European Parliament and the Council of European Union) (2) Have worked in the Emergency Department for a period of at least 6 months. A total of 277 participants were eligible to participate and 224 questionnaires were completed and returned (174 of 210 eligible nurses – response rate 82.8%, and 50 of the 67 physicians – response rate 74.65%) (overall response rate was 80.9%). 3.4. Instruments

3. Methods

The instruments used were (a) the Revised Professional Practice Environment (RPPE) Scale (Erickson et al., 2009) and (b) the Safety Climate Domain of the Emergency Medical Services Safety Attitudes Questionnaire (EMS-SAQ) (Patterson et al., 2010). Furthermore, participants were asked to provide demographic and other information such as age, gender, total work experience and number of years of experience in the ED. The RPPE scale designed in 1998 (Erickson et al., 2004) consists of 39 items and measures eight professional practice environment characteristics, that is: leadership and autonomy in clinical practice (5 items), control over practice (5 items), communication about patients (3 items), teamwork (4 items), handling disagreements (9 items), staff relationships (2 items), internal work motivation (8 items) and cultural sensitivity (3 items). The RPPE uses a 4-point Likert-type scale for each item which ranges from strongly disagree (option 1) to strongly agree (option 4). The tool was shown to have good psychometric properties in a sample of 849 professionals in Boston (USA) (Erickson et al., 2004). The Emergency Medical Services Safety Attitudes Questionnaire (EMS-SAQ) is a 60item survey tool that collects information on respondents’ perceptions of the safety culture of an organization. Responses to EMS-SAQ items are captured on a 5-point Likert scale. It measures six domains of safety culture: Safety Climate, Teamwork Climate, Perceptions of Management, Stress Recognition, Perceptions of Working Conditions and Job Satisfaction. The questionnaire was originally developed by adapting the previously validated Intensive Care Unit Safety Attitudes Questionnaire (Patterson et al., 2010; Sexton et al., 2006). The safety climate score is scaled to range from 0 to 100. (1 = Disagree Strongly = 0, 2 = Disagree Slightly = 25, 3 = Neutral = 50, 4 = Agree Slightly = 75, 5 = Agree Strongly = 100). A score of more than or equal to 75 indicates a positive safety climate. The Safety Climate Domain of the EMS-SAQ was translated into the Greek language and the backward and forward translation was followed by discussions and agreement about the content, concept criteria and semantic equivalence of the terms used (MAPI Research Institute, 2009). The Safety Climate Domain included seven questions (3, 4, 8, 9, 14, 15, 22 – Question 9 was reverse coded to match the positive valence of the other questions).

3.1. Settings

4. Ethical considerations

Autonomous EDs are located in every Cyprus District General Hospital (5 in number). A descriptive correlational study was performed among all nurses and physicians working in all EDs across the five public general hospitals on the island.

Permissions were granted by the Research Committee of the Cyprus Ministry of Health and the Cyprus National Bioethics Committee. Permissions to use the instruments were obtained directly from the authors. Contact persons in each hospital distributed the

(i) What is the magnitude of the association between physicians’ and nurses’ perceptions of professional practice environment and patient safety? (ii) Are there between-professions differences in perceptions of the elements of the professional environment and patient safety? (iii) Which characteristics of the professional environment are more strongly associated with perceptions of patient safety?

152

P. Lambrou et al./International Emergency Nursing 23 (2015) 150–155

questionnaires to the physicians and nurses who, upon completion, deposited them in sealed envelopes in designated boxes or offices in each participating ED. Before the respondents received the questionnaire, written and verbal information about the purpose of the study was provided, including the voluntary nature of their participation, the right to withdraw and a guarantee of the maintenance of anonymity and confidentiality of the data. 5. Data and results 5.1. Data analysis Descriptive statistics such as means and standard deviations were calculated for the overall scale scores for RPPE and EMS-SAQ, the sub-scales of the RPPE as well as for each item separately. The internal consistency of each of the RPPE sub-scales was assessed using Cronbach’s alpha coefficient. Differences in mean scores between the two study groups (nurses and physicians) were viewed as by demographic characteristics of the participants (such as agegroup, gender, length of employment) and were assessed using one way ANOVA or independent t-tests as appropriate. Bivariate association between the overall and individual RPPE sub-scales and the EMS-SAQ was evaluated using Pearson’s correlation coefficients. Additionally, all eight sub-scales of the RPPE were entered in a stepwise multiple regression model in order to assess which of the RPPE factors are the best predictors of EMS-SAQ scores and the total variance explained. Logistic regression analyses explored the relationships between the professional group, the gender of the participants as independent variables and the safety domain as dependent binary variable. Data were analyzed using SPSS for Windows 21.0 (SPSS Inc. Chicago, IL, USA). The Cronbach’s alpha coefficient was found for the RPPE as total = 0.88 and for the 8 subscales separately as displayed in Table 1. The same procedure was followed for EMS-SAQ (Safety Climate Domain). The Cronbach’s alpha coefficient was 0.61. This coefficient is relatively low compared with other studies where the same instrument was used (Modak et al., 2007; Patterson et al., 2010; Sexton et al., 2006). Responses from the 7 questions relating to safety climate were averaged. Table 1 summarizes the results of the reliability of RPPE, RPPE and 8 factors’ mean values and mean values of EMS-SAQ. Outliers as regards the eight subscales of the RPPE were identified. Further analyses were conducted without the outliers for “communication about patients”, “teamwork” and “handling disagreements” but results relating to reliability of these three subscales did not change. The majority of the respondents (49.3%) were between 25 and 35 years of age. There was a substantial age difference between the two professional groups as 58.4% of the nurses were younger than 35 years of age whereas this figure was only 18% in the case of the

physicians. Just over half of the respondents were female (53.9%) and this was the case among both physicians and nurses (56.3% and 53.2% respectively). This reflects the true gender distribution in ED based on official statistics (Cyprus Statistical Service, 2011). Most of the respondents had long professional experience and were also well experienced in the ED, especially the physicians (x = 19.65, SD = 8.49) as compared to nurses (x = 7.63, SD = 6.97). The participants stated that they provided care for an average of 67 patients per shift. More than 87% of the participants (nurses and physicians) had obtained an additional certification after their basic training. Regarding the scores of the RPPE, the mean value for the overall scale was x = 2.79 (SD = 0.30). On average, the physicians assessed the RPPE slightly higher with x = 2.84 (SD = 0.25) compared to x = 2.73 (SD = 0.33) among nurses; P-value for difference = 0.07. Overall, the highest mean score was for “teamwork” x = 3.20 (SD = 0.43) while the lowest score was for subscale “control over practice” x = 2.03 (SD = 0.49). As shown in Table 1, statistically significant differences were observed between the two professional groups in terms of “staff relationships”, “internal motivation” and “cultural sensitivity”. The mean score for the Safety Climate Domain of the EMS-SAQ was x = 3.18 (SD = 0.51) for the total sample. With a mean score of x = 3.25 (SD = 0.48) among physicians and x = 3.16 (SD = 0.51) among nurses, there were no statistically significant differences between the two study groups in their assessment of patient safety. Mean domain scores equal to or above 75 are considered “high” or “positive” scores and indicate that an ED’s employees have a favorable (or positive) perception of an agency’s internal systems and policies that impact on everyday activities with respect to a specific domain. Low scores reflect a less than favorable or negative employee perception within a domain. The safety climate score in this study was particularly low with a mean x = 43.75 (SD = 14.25). There were moderate positive correlations between RPPE and all its components with the EMS-SAQ (all Pearson’s correlation coefficients statistically significant at the 0.01 level). The factors with the strongest correlation with safety were “leadership” (r = 0.53), followed by “control over practice” (r = 0.48), “staff relations” (r = 0.45) and “cultural sensitivity” (r = 0.44) while the weakest was with “teamwork” (r = 0.26). The rest of the correlations were “communication about patients” (r = 0.32), “handling disagreement” (r = 0.32), and “internal motivation” (r = 0.31). These are shown in Tables 2 and 3 along with the results of the simple and multiple linear regression analysis. The impact of the eight RPPE subscales (independent variables) on safety climate (dependent) was explored using simple linear and stepwise multiple regression. The results of the simple linear regression indicate that “leadership” explains 28% of the variance in “safety”. “Control over practice” explains 22% of the variance in “safety”. The analytical findings are shown in Table 3.

Table 1 Reliability of RPPE, RPPE 8 factors’ mean values, mean values of EMS-SAQ and standard deviation (SD).

RPPE(1–4) Leadership and autonomy in clinical practice Control over practice Communication about patients Teamwork Handling disagreements Staff relationships Internal work motivation Cultural sensitivity EMS-SAQ instrument (1–5)

Cronbach’s alpha

Number of items

Mean and SD: total sample (N = 224)

Mean and SD: physicians (N = 50)

Mean and SD: nurses (N = 174)

Maximum– minimum

P-value*

0.88 0.74 0.81 0.36 0.32 0.60 0.71 0.82 0.77 0.61

39 5 5 3 4 9 2 8 3 7

2.79 (0.30) 2.63 (0.50) 2.03 (0.49) 2.89 (0.44) 3.20 (0.43) 2.91 (0.32) 2.67 (0.60) 3.08 (0.46) 2.59 (0.59) 3.18 (0.51)

2.84 (0.25) 2.69 (0.39) 2.23 (0.47) 2.98 (0.43) 3.29 (0.38) 3.02 (0.27) 2.94 (0.42) 2.98 (0.28) 2.62 (0.42) 3.25 (0.48)

2.73 (0.33) 2.61 (0.53) 1.97 (0.49) 2.87 (0.44) 3.18 (0.44) 2.88 (0.33) 2.60 (0.63) 3.11 (0.50) 2.58 (0.63) 3.16 (0.51)

3.52–1.90 2.84–2.46 2.14–1.90 3.45–2.61 3.50–2.52 3.52–2.33 2.73–2.61 3.36–2.72 2.74–2.39 4.43–1.86

0.07 0.06 0.81 0.95 0.48 0.57 0.00 0.00 0.02 0.31

* Difference in mean values is significant at the 0.05 level.

P. Lambrou et al./International Emergency Nursing 23 (2015) 150–155

153

Table 2 Correlation and regression coefficients from simple linear regression model of the 8 RPPE subscales (independent variables) on safety (dependent variable). RPPE scale and subscales

Adjusted R2

Simple linear regression

RPPE Leadership Control over practice Staff relations Communication Teamwork Motivation Cultural sensitivity Disagreement

Unstandardized b coefficient (per 1 unit increase)

St. error

P-value

r

R2

0.96 0.53 0.49 0.37 0.36 0.30 0.34 0.37 0.49

0.09 0.05 0.06 0.05 0.07 0.07 0.07 0.05 0.09

0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

0.57 0.53 0.48 0.44 0.32 0.25 0.31 0.46 0.32

0.33 0.28 0.22 0.19 0.10 0.06 0.09 0.19 0,10

Table 3 Stepwise multiple regression model of the 8 RPPE subscales (independent variables) on safety (dependent variable).

Step 1: Constant Leadership and autonomy Step 2: Constant Leadership and autonomy Control over practice Step 3: Constant Leadership and autonomy Control over practice Cultural sensitivity

b

SEb

β

Sig.

Αdjusted R2

1.78 0.53

0.15 0.05

0.13

0.00 0.00

0.28

1.54 0.39 0.29

0.16 0.06 0.06

0.39 0.29

0.00 0.00 0.00

0.35

1.46 0.33 0.26 0.12

0.16 0.07 0.06 0.06

0.33 0.26 0.14

0.00 0.00 0.00 0.03

0.36

All eight subscales of the RPPE were used in a stepwise multiple regression analysis to predict “safety”. The prediction model was reached in 3 steps with five subscales removed. The emergent model was statistically significant (F-value (3.22) = 41.09, P < 0.001) explaining 35.60% (adjusted R2) of the variance of “safety”. Three of the RPPE sub-scales (“leadership”, “control over practice” and “cultural sensitivity”) were statistically significant predictors of this model (Table 3). No problems with multi-co-linearity were detected based on tolerance values ranging from 0.64 to 0.73 and VIF values ranging from 1.38 to 1.56. Logistic regression analyses explored the relationships between safety as dependent variable and professional group and gender as independent variables. The odds of a nurse reporting positive safety perceptions are about 2 times the odds of a physician. The odds of a male reporting positive safety perceptions are about 7 times the odds of a female (Table 4).

6. Discussion The results of our study showed that physicians and nurses have different perceptions of their PPE in the ED, especially as regards staff relationships (P = 0.00), internal work motivation (P = 0.00), and cultural sensitivity (P = 0.024). Relating to patient safety, it seems that both professional groups share similar perceptions. This approach of exploring the perceptions of both physicians and nurses

0.32 0.27 0.22 0.19 0.09 0.06 0.09 0.18 0.09

in the EDs is important, given the complexities of the work environment and the nature of their work in the particular area and its effects on patient safety. However, because there are very few national or international studies specifically on the ED, the discussion is more general including the professional environment in other settings of acute care hospitals. The participants in our survey assessed RPPE index at a higher score compared to surveys of 2011, 2012 and 2013 that included samples from Cyprus but from different settings where only nurses took part in those surveys (Papastavrou et al., 2014a,b). Specifically, the mean RPPE value of our research was x = 2.79 , while in previous surveys nurses gave lower scores, for example x = 2.68 in orthopedic and surgical wards (Papastavrou et al., 2012), and x = 2.76 in medical-surgical units (Papastavrou et al., 2014a). Physicians graded this indicator with x = 2.84 in contrast with nurses who gave a mean of x = 2.73. In another study in Finland (Suhonen et al., 2013), in a sample of 874 nurses working in elderly nursing centers, the results of the RPPE index ranged from x = 2.84 to x = 2.90. The evaluation of nurses in all three above studies is about the same. One possible explanation for the overall higher assessment of our research as well as the higher assessment by nurses (in comparison to the results of the other studies carried out in Cyprus) may be the fact that the EDs are considered to be a kind of “special” department (Georgopoulos, 1985; Woloshynowych et al., 2006) in the hospital where the professionals should acquire additional qualifications such as Advanced Trauma Life Support (ATLS), Advanced Life Support (ALS), Immediate Life Support (ILS) and Prehospital Trauma Life Support (PHTLS) and work in teams to be able to carry out their mission. Working in teams is emphasized in the policy statement of the European Society for Emergency Medicine (2013). Nurses with higher levels of education report higher levels of job satisfaction than those with lower educational level (Coomber and Barriball, 2007). The previous surveys mentioned with the use of the RPPE (Farmakas et al., 2014; Papastavrou et al., 2014a,b) revealed the highest value among the eight RPPE subscales in “internal motivation”. The same pattern follows and in a recent survey conducted in Finland in 2012 (Suhonen et al., 2013) as well as in other surveys carried out in Greece and Cyprus (Kontodimopoulos et al., 2009; Lambrou et al., 2010), where “motivation” records the highest value. In our survey, this factor ranked second and the top ranking factor was “teamwork”. This is consistent with recent research in the United States, where good

Table 4 Logistic regression model of safety (dependent variable) and gender and professional group (independent variables). Safety Gender – (0 = male, 1 = female) Females vs. males Profession – (0 = physicians, 1 = nurses) Physicians vs. nurses

% Positive perception

Simple model (95%CI)

P-value

Multivariate model (95%CI)

P-value

0.14 (0.30–0.65)

0.01

0.14 (0.03–0.65)

0.01

1.62 (0.35–7.65)

0.54

1.52 (0.32–7.29)

0.59

1.7% vs. 10.9% 4.0% vs. 6.3%

154

P. Lambrou et al./International Emergency Nursing 23 (2015) 150–155

teamwork is associated with increased satisfaction with the work environment (Ajeigbe et al., 2013). In most cases, excluding only the factor “motivation”, the physicians assessed all the subscales with higher values. Statistically significant difference was recorded between physicians and nurses in the mean values of the subscales “staff relationships”, “internal motivation” and “cultural sensitivity”. This is in contrast with the findings of a study (targeted to physicians and nurses) in ED settings where “motivation” was assessed with a higher score by physicians and “internal communication” was evaluated with a higher score by nurses (Lin et al., 2008). The factor “motivation” consists of questions related to pride and appreciation and is considered as an intrinsic factor according to Herzberg (House and Wigdor, 1967). In our survey, physicians working in the ED (unlike the rest of their colleagues in the hospital) work on a shift system with a different remuneration rate as regards their overtime payments, whereas nurses all over the hospital work under the same system. Recent research carried out in Cyprus (Lambrou et al., 2010) presented statistically significant differences between remuneration and hospital department, especially for ER physicians. This may explain the difference presented in our results (Kontodimopoulos et al., 2009; Paleologou et al., 2006). In any case, this issue needs further investigation. The subscale “control over practice” has the lowest score in our study. This finding is consistent with nurses’ reports from other studies. The lowest score provided by nurses can consequently explain the lower rating of the professional environment (Ajeigbe et al., 2013). The assessment of “autonomy”, “control over practice” and “staff relationships” are associated with lower rating for the professional environment (Panunto and Guirardello, 2013). As regards the evaluation of the “cultural sensitivity” subscale which has a lower score in our study in relation to the previous surveys in Cyprus, this could be explained by the fact that the EDs in Cyprus are visited by those with urgent problems regardless of nationality. Taking into account that according to Eurostat figures (Eurostat, 2014), Cyprus ranks second after Luxembourg in the European Union (EU) in the proportion of immigrants to the native population (27 immigrants every 1000 inhabitants), it is easily understood how big the number of foreigners visiting Cyprus’ EDs is, especially after the accession of Cyprus into the EU in 2004. A comparison across the five provinces where the research was conducted revealed statistically significant differences in 4 out of 8 subscales and the total RPPE. This finding is in line with the findings of a recent study carried out in Sweden in a sample of 11,000 registered nurses (Lindqvist et al., 2013) where nurses in small hospitals evaluated their professional environment with higher scores than those in bigger hospitals. In our research, where “teamwork” concerns the communication of the ED with the other hospital departments, the smallest ED registers the highest score. This can be explained by the fact that in a smaller hospital, employees know each other better as their number is limited. The findings of this study demonstrated a positive correlation between nurses’ and physicians’ perceptions of professional practice environment with patient safety, which goes some way to confirming this relationship. The elements of the professional practice environment were all positively and significantly correlated with the patient safety, except the “teamwork” factor, for which a weak correlation was found. Participants’ perceptions of professional practice environment explained 28% of the variance in patient safety and within these perceptions the concept of leadership seems to be the most influential and explanatory of their perceptions of safe care. This is consistent with the results of Huang’s research where “lower perceptions of management were significantly associated with higher hospital mortality” (Huang et al., 2010, p. 155). In our study, physicians had higher safety culture scores than nurses. This is in line with other studies (Patterson et al., 2010; Shaw et al., 2009). The physicians in our survey graded RPPE with a higher score, so this could be an explanation

of this phenomenon, as safety climate surveys reflect the influence of management on safety (Zohar, 2002). Perceptions of safety varied with total work experience and experience in the ED. Participants with less working experience (less than 10 years) gave a higher score to safety than those with an experience of more than 10 years. On the other hand, those with less than 5 years’ experience in the ED gave a lower value to safety than the more experienced ones. As regards age and safety, the younger respondents (less than 35 years old) rated safety lower than those between 36 and 55 and the older ones gave the highest score. Nevertheless, no significant differences were observed between these variables. This finding is in contrast with the results of Shaw et al.’s study (Shaw et al., 2009) where nurses and physicians with less than 3 years of experience reported higher safety climate scores than did those with more experience. This difference may be explained by the different sample used by Shaw et al. (2009) who investigated patient safety in pediatric ED. 6.1. Clinical implications There are several implications for practice arising from the results of this study. Their importance lies in association of patient safety with certain factors of the professional practice environment that can be modified and changed. The findings point to the need for a continuous assessment of the level of patient safety and provide data to medical and nursing management for improving the PPE, so as to facilitate the development of a safe care environment. This study also provides evidence as to the importance of leadership among physicians and nurses who work together to provide all necessary care to patients. The clinical significance of the results of this study is that they can provide nurse and physician leaders with information they need to focus on leadership interventions on the problematic areas to create an environment which is conducive to the delivery of safe and high quality care. 6.2. Limitations Our research included nurses and physicians and is the first of its kind to be conducted simultaneously in both professional groups in EDs as regards the Professional Practice Environment Questionnaire. Some questions could have been perceived by the participants in different ways, and this may have had an impact on the results. The sample, although the response rate was quite high, is not large enough to draw firm conclusions. In addition, a relatively low Cronbach alpha was observed for two factors of the PPE as well as for EMS-SAQ (safety domain), but this may be explained by the small numbers of items in each of these. 7. Conclusions This study provides preliminary evidence of an association between professional practice environment ratings, especially “leadership and autonomy”, and “safety culture” scores in the EDs. Achievement of a culture conducive to patient safety may be an admirable goal in its own right, but more effort should be expended on understanding the relationship between measures of a positive professional practice environment and a patient safety climate, which in turn is directly related to patient outcomes. Future work should continue to develop methods for assessing professional practice environments and safety culture associated with desirable patient outcomes. Acknowledgements We would like to thank Jeffrey M. Adams for giving us the permission to use the RPPE questionnaire and Weaver Matthew for

P. Lambrou et al./International Emergency Nursing 23 (2015) 150–155

giving us the permission to translate and use the EMS-SAQ (Safety Climate Domain). The authors are grateful to the nurses and physicians who participated in the study and Gerry Barret for the language checking. References Adriaenssens, J., De Gucht, V., Van Der Doef, M., Maes, S., 2011. Exploring the burden of emergency care: predictors of stress-health outcomes in emergency nurses. Journal of Advanced Nursing. 67, 1317–1328. Aiken, L.H., Sloane, D.M., Clarke, S., Poghosyan, L., Cho, E., You, L., et al., 2011. Importance of work environments on hospital outcomes in nine countries. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care. 23, 357–364. Ajeigbe, D., McNeese-Smith, D., Leach, L.S., Phillips, L.R., 2013. Nurse-physician teamwork in the emergency department: impact on perceptions of job environment, autonomy, and control over practice. The Journal of Nursing Administration. 43, 142–148. Ajeigbe, D., McNeese-Smith, D., Phillips, L., Leach, L., 2014. Effect of Nurse-physician teamwork in the emergency department nurse and physician perception of job satisfaction. The Journal of Nursing Care. 3, 141. doi:10.4172/2167-1168.1000141. Coomber, B., Barriball, K.L., 2007. Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature. International Journal of Nursing Studies. 44, 297–314. Cyprus Statistical Service, 2011. Health and Hospitals Statistics, Nicosia. Dekeyser Ganz, F., Toren, O., 2014. Israeli nurse practice environment characteristics, retention, and job satisfaction. Israel Journal of Health Policy Research. 3, 7. Erickson, J., Jones, D., Ditomassi, M., 2012. Fostering Nurse-Led Care: Professional Practice for the Bedside Leader. From Massachusetts General Hospital. Sigma Theta Tau, Indianapolis, IN. Erickson, J.I., Duffy, M.E., Ditomassi, M., Jones, D., 2009. Psychometric evaluation of the Revised Professional Practice Environment (RPPE) scale. The Journal of Nursing Administration. 39, 236–243. Erickson, J.I., Duffy, M.E., Gibbons, M.P., Fitzmaurice, J., Ditomassi, M., Jones, D., 2004. Development and psychometric evaluation of the Professional Practice Environment (PPE) scale. Journal of Nursing Scholarship. 36, 279–285. European Society for Emergency Medicine (2013) Policy statement on emergency medicine in Europe. http:// www.eusem.org/cms/assets/1/pdf/policy accessed 8/8/2014. Eurostat (2014) Migration and migrant population statistics. http:// epp.eurostat.ec.europa.eu/statistics_explained/index.php/Migration accessed 8/8/2014. Farmakas, A., Papastavrou, E., Siskou, O., Karayiannis, G., Theodorou, M., 2014. Challenges in mental health nursing: working in institutional or community settings? Journal of Psychiatric and Mental Health Nursing. 21, 39–45. Georgopoulos, B.S., 1985. Organization structure and the performance of hospital emergency services. Annals of Emergency Medicine. 14, 677–684. House, R., Wigdor, L., 1967. Herzberg’s dual-factor theory of job satisfaction and motivation: a review of the evidence and a criticism. Personnel Psychology. 20, 369–390. Huang, D.T., Clermont, G., Kong, L., Weissfeld, L.A., Sexton, J.B., Rowan, K.M., et al., 2010. Intensive care unit safety culture and outcomes: a US multicenter study. International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care. 22, 151–161. International Council of Nurses, International Hospital Federation, International Pharmaceutical Federation, World Confederation for Physical Therapy, World Dental Federation, World Medical Association (2008) Positive practice environments for health care professionals. http://www.whpa.org/ ppe_fact_health_pro.pdf Kontodimopoulos, N., Paleologou, V., Niakas, D., 2009. Identifying important motivational factors for professionals in Greek hospitals. BMC Health Services Research. 9, 164.

155

Lambrou, P., Kontodimopoulos, N., Niakas, D., 2010. Motivation and job satisfaction among medical and nursing staff in a Cyprus public general hospital. Human Resources for Health. 8, 26. Laschinger, H., Leiter, M., 2006. The impact of nursing work environments on patient safety outcomes: the mediating role of burnout engagement. The Journal of Nursing Administration. 36, 259–267. Lin, B.Y.-J., Hsu, C.-P.C., Chao, M.-C., Luh, S.-P., Hung, S.-W., Breen, G.-M., 2008. Physician and nurse job climates in hospital-based emergency departments in Taiwan: management and implications. Journal of Medical Systems. 32, 269–281. Lindqvist, R., Alenius, L.S., Griffiths, P., Runesdotter, S., Tishelman, C., 2013. Structural characteristics of hospitals and nurse-reported care quality, work environment, burnout and leaving intentions. Journal of Nursing Management. doi:10.1111/ jonm.12123. MAPI Research Institute (2009) Linguistic validation methodology. http://www.mapiinstitute.com/linguistic-validation/methodology. Modak, I., Sexton, J.B., Lux, T.R., Helmreich, R.L., Thomas, E.J., 2007. Measuring safety culture in the ambulatory setting: the safety attitudes questionnaire – ambulatory version. Journal of General Internal Medicine. 22, 1–5. Paleologou, V., Kontodimopoulos, N., Stamouli, A., Aletras, V., Niakas, D., 2006. Developing and testing an instrument for identifying performance incentives in the Greek health care sector. BMC Health Services Research. 6, 118. Panunto, M.R., Guirardello, E.D.B., 2013. Professional nursing practice: environment and emotional exhaustion among intensive care nurses. Revista Latino-Americana de Enfermagem. 21, 765–772. Papastavrou, E., Efstathiou, G., Acaroglu, R., DA Luz, M.D., Berg, A., Idvall, E., et al., 2012. A seven country comparison of nurses’ perceptions of their professional practice environment. Journal of Nursing Management. 20, 236–248. Papastavrou, E., Andreou, P., Tsangari, H., Schubert, M., De Geest, S., 2014a. Rationing of nursing care within professional environmental constraints: a correlational study. Clinical Nursing Research. 23, 314–335. Papastavrou, E., Efstathiou, G., Lemonidou, C., Kalafati, M., Katajisto, J., Suhonen, R., 2014b. Cypriot and Greek nurses’ perceptions of the professional practice environment. International Nursing Review. 1–8. Papathanassoglou, E.D.E., Karanikola, M.N.K., Kalafati, M., Giannakopoulou, M., Lemonidou, C., Albarran, J.W., 2012. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. American Journal of Critical Care. 21, e41–e52. Patterson, P.D., Huang, D.T., Fairbanks, R.J., Wang, H.E., 2010. The emergency medical services safety attitudes questionnaire. American Journal of Medical Quality. 25, 109–115. Sexton, J.B., Helmreich, R.L., Neilands, T.B., Rowan, K., Vella, K., Boyden, J., et al., 2006. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Services Research. 6, 44. Shaw, K.N., Ruddy, R.M., Olsen, C.S., Lillis, K.A., Mahajan, P.V., Dean, J.M., et al., 2009. Pediatric patient safety in emergency departments: unit characteristics and staff perceptions. Pediatrics. 124, 485–493. Suhonen, R., Stolt, M., Gustafsson, M.-L., Katajisto, J., Charalambous, A., 2013. The associations among the ethical climate, the professional practice environment and individualized care in care settings for older people. Journal of Advanced Nursing. 1–13. Verbeek-Van Noord, I., Wagner, C., Van Dyck, C., Twisk, J.W., De Bruijne, M.C., 2014. Is culture associated with patient safety in the emergency department? A study of staff perspectives. International Journal for Quality in Health Care, 26, 64–70. Wiskow, C., Albreht, T., De Pietro, C., 2010. How to Create an Attractive and Supportive Working Environment for Health Professionals. World Health Organization, Copenhagen. Woloshynowych, M., Davis, R., Brown, R., Wears, R., Vincent, C., Lyons, M., 2006. Enhancing Safety in Accident and Emergency Care. Clinical Safety Research Unit, London. Zohar, D., 1980. Safety climate in industrial organizations: theoretical and applied implications. The Journal of Applied Psychology. 65, 96–102. Zohar, D., 2002. The effects of leadership dimensions, safety climate, and assigned priorities on minor injuries in work groups. Journal of Organizational Behavior. 23, 75–92.